Ankyloglossia with some symptoms missing

Hi Sandra, I look through your website weekly and read archives and current questions–I learn a lot! I saw a 6 year, 5 month old last week for tight lingual frenulum. He came via an ENT who would perform frenectomy if speech problems present (hence referral to me). Parents unsure of surgery. My bottom line question is: when there appears to be NO current obvious difficulties (see below) in the presence of a tight lingual frenulum (per measurements and appearance), should one proceed with frenectomy? And if a family decides to wait until more information comes to light (e.g., orthodontic intervention) does the response to surgery get harder with age (doing now at 6 versus when 12)? They asked me that question specifically. Is there contraindication to waiting? I included bits and pieces from my evaluation so you could see the whole picture. Any advice you have would be so beneficial…as I don’t have others to bounce this information off of! Thank you so much! Here is more information about him: Mom reports he had a poor latch for breastfeeding, but could latch easily for bottle feeding. Parents deny any difficulties with chewing or eating now. Not a messy eater. Parent don’t observe use of fingers in the mouth for cleaning out buccal cavities. Parents deny swallowing difficulties. Mom reports no cavities (very good hygiene), no extensive cleaning required at dental exams. No orthodontic care yet. ROM Quick Tongue Tie Assessment: Max Mouth Opening (MOmax): 39-40mm Max mouth opening with tongue tip to spot: 10-12mm Estimated MOWS: <10mm MOWS estimated value is less than 1/2 the MOmax measurement suggesting frenulum can’t be fully functional. He can’t achieve tongue tip with narrow tongue outside of oral cavity, rather tongue tip is notched like a heart. Within the oral cavity, tip somewhat achieved though has appearance of squared tip. Able to elevate tongue tip to incisive papilla with mouth opening (distance of 10-12 mm between lower edge of maxillary incisor and upper edge of mandibular incisor). My assessment: Ankyloglossia characterized by anterior frenum attachment on the tongue, frenum attachment on low-mid portion of inferior alveolar ridge, appearance of thin composition, and measurements that would suggest decreased functioning of the frenum (limitations of movement). Many of the areas in which a short lingual frenulum could be a factor are non-contributory at this time, which doesn’t support consideration of frenum surgery: His speech is precise and no articulatory errors related to frenum function are present. Parents deny any difficulty with oral preparation and swallowing of food. Parents deny obvious difficulty with cleaning buccal cavity. Parents deny any obvious social implications (e.g., can’t lick ice cream cone, etc.) Parents are not aware of any dental hygiene issues. Parents are cautioned, though, that this tight frenum may impede proper positioning of the tongue within the oral cavity while the tongue is at rest, which holds the potential for negatively affecting dentition, palatal growth, tooth eruption, and oral hygiene. Parents are encouraged to take all of this into consideration in their decision-making process.  

Hi, I’m trying to get the word out that “speech” is only one of the many possible symptoms and difficulties.  Unfortunately many think “speech” is the main problem.  Truthfully, I think that other professionals don’t have the background to make the decision and leave it up to SLPs, many of whom don’t have a clue.  But YOU DO because you took the intensive course!  I’ll comment below, also, within the eval info, so you can better make the decision of what to do.

Information about him: Mom reports he had a poor latch for breastfeeding, but could latch easily for bottle feeding. That is a big sign, per articles and research of the International Board of Lactation Consultant.   Parents deny any difficulties with chewing or eating now. Not a messy eater. Some tend to eat even more slowly, more often the girls; others faster while taking large bites, more often the boys… QTT Quick Tongue Tie Assessment: Max Mouth Opening (MOmax): 39-40mm Max mouth opening with tongue tip to spot: 10-12mm   If you did a fairly good measure, then this is a rather severe finding. It would be unusual if the patient does not have some concomitant issues with such a differential in the numbers of the QTT assessment. Estimated MOWS: <10mm MOWS estimated value is less than 1/2 the MOmax measurement suggesting frenulum can’t be fully functional. He can’t achieve tongue tip with narrow tongue outside of oral cavity, rather tongue tip is notched like a heart. And here, also, is a severe indicator of ankyloglossia.  Heart-shaped is a strong symptom and means that he cannot adequately cleanse his mouth, reach his posterior area of the “gums” or teeth, etc.  Within the oral cavity, tip somewhat achieved though has appearance of squared tip. Able to elevate tongue tip to incisive papilla with mouth opening (distance of 10-12 mm between lower edge of maxillary incisor and upper edge of mandibular incisor).  I’m not sure how he can possibly create any real tip on the tongue if it is heart-shaped.  I don’t think it is possible to be both heart shaped and pointed. My assessment: Ankyloglossia characterized by anterior frenum attachment on the tongue, frenum attachment on low-mid portion of inferior alveolar ridge, appearance of thin composition, and measurements that would suggest decreased functioning of the frenum (limitations of movement). Many of the areas in which a short lingual frenulum could be a factor are non-contributory at this time, which doesn’t support consideration of frenum surgery: His speech is precise (but can he do the following rapidly and repeatedly….diadochokinetic testing, rapid repeat of simple tongue twisters, changing volume and speeds easily when counting or doing other memorized phrases; changing pitch with ease…..and no articulatory errors related to frenum function are present.  I would demo to the parents that the child cannot separate lingual and mandible/jaw movements adequately, which I am certain he cannot; also, I find it difficult to believe that his connected speech isn’t compromised by some of the things just mentioned. I hope this is helpful,  and thank you for a very thoughtful set of questions and your conscientious attempt to offer the best possible treatment for your patients! Sincerely, Sandra